CALL ¾ THE HEALTH CARE FRAUD HOTLINE

202-418-3300

OR WRITE TO:

United States Office of Personnel Management

Office of the Inspector General Fraud Hotline

1900 E Street NW Room 6400

Washington, DC20415-1100

Identification cards

We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your Employee Express confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 608/260-3170 or write to us at PO Box 44971, Madison WI 53744-4971. You may also request replacement cards through our Web site at www.ghc-hmo.com.

Where you get covered care

You get care from “Plan providers” and “Plan facilities.” You will only pay co-payments or coinsurance, and you will not have to file claims.

Plan providers

Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential Plan providers according to national standards.

We list Plan providers in the provider directory, which we update periodically. The list is also on our Web site.

Plan facilities

Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which we update periodically. The list is also on our Web site.

What you must do to get covered care

It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is important since your primary care physician provides or arranges for most of your health care. If you need assistance, please call the GHC Member Services Department at 608/828-4853.

Primary care

Your primary care physician can be a family practitioner, internist or a pediatrician. (You may also select from affiliated physician assistants or nurse practitioners.)Your primary care physician will provide most of your health care, or give you a referral to see a specialist.

If you want to change primary care physicians or if your primary care physician leaves the Plan, call us. We will help you select a new one.

Specialty care

Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must return to the primary care physician after the consultation, unless your primary care physician authorized a certain number of visits without additional referrals. The primary care physician must provide or authorize all follow-up care. Do not go to the specialist for return visits unless your primary care physician gives you a referral. However, you may see the following Plan providers without a referral: mental health, substance abuse, vision, dental, chiropractic.

Here are some other things you should know about specialty care:

If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals. Your primary care physician will use our criteria when creating your treatment plan (the physician may have to get an authorization or approval beforehand).

If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what treatment you need. If he or she decides to refer you to a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.

If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.

If you have a chronic and disabling condition and lose access to your specialist because we:

- Terminate our contract with your specialist for other than cause; or

- Drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB program Plan; or

- Reduce our service area and you enroll in another FEHB Plan,

you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us, or if we drop out of the Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.

Hospital care

Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility.

If you are in the hospital when your enrollment in our Plan begins, call our Care Management department immediately at 608/257-5294. If you are new to the FEHB Program, we will arrange for you to receive care.

If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

You are discharged, not merely moved to an alternative care center; or

The day your benefits from your former plan run out; or

The 92^nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such case, the hospitalized family member’s benefits under the new plan begin on the effective date of enrollment.

Circumstances beyond our control

Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all reasonable efforts to provide you with the necessary care.

Services requiring our prior approval

Your primary care physician has authority to refer you for most services. For certain services, however, your physician must obtain approval from us. Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice.

We call this review and approval process Prior Approval. Your physician must obtain Prior Approval for all services that require prior authorization, such as, but not limited to:

Hospital Care

Referring you to a specialist

Recommending follow-up care

All surgical procedures

All occupational, physical and speech therapy

Infertility services

Breast reduction mammoplasty

Plastic surgery

Transplant of any organ

All outpatient surgery

Growth Hormone Therapy (GHT)

GHC will not guarantee payment for services that require prior authorization which were not prior authorized unless emergent in nature.

Copayments

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

Example: When you see your primary care physician you pay a copayment of $10 per office visit.

Deductible

We do not have a deductible.

Coinsurance

Coinsurance is the percentage of our allowance that you must pay for your care.

Example: In our Plan, you pay 20% of our allowances for Durable Medical Equipment and Orthopedic and Prosthetic devices and 50% of our allowances for sexual dysfunction drugs and preventive dental care services if a non-participating dentist is used.

Your catastrophic protection out-of-pocket maximum

We do not have a catastrophic protection out-of-pocket maximum.

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Here are some important things you should keep in mind about these benefits:

Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care.

We have no calendar year deductible.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

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Professional services of physicians

In physician’s office

In an urgent care center

Office medical consultations

Second surgical opinion

At home

$10 per office visit

Professional services of physicians

During a hospital stay

In a skilled nursing facility

Nothing

Tests, such as:

Blood tests

Urinalysis

Non-routine pap tests

Pathology

X-rays

Non-routine Mammograms

CAT Scans/MRI

Ultrasound

Electrocardiogram and EEG

Nothing

You pay

Routine screenings, such as:

Total Blood Cholesterol - once every three years

Colorectal Cancer Screening, including

- Fecal occult blood test

- Sigmoidoscopy, screening – every five years starting at age 50

- Double contrast barium enema – every five years starting at age 50

- Colonoscopy screening – every ten years starting at age 50

Routine Prostate Specific Antigen (PSA) test – one annually for men age 40 and older

Routine pap test

Note: The office visit is covered if pap test is received on the same day; see Diagnosis and Treatment, above.

Routine mammogram – covered for women age 35 and older, as follows:

From age 35 through 39, one during this five year period

From age 40 through 64, one every calendar year

At age 65 and older, one every two consecutive calendar years

Routine immunizations, limited to:

Tetanus-diphtheria (Td) booster – once every 10 years, ages19 and over (except as provided for under Childhood immunizations)

Influenza vaccine, annually

Pneumococcal vaccine, age 65 and older

Physical exams required for travel or for attending school or camp.

: Note: Travel related immunizations may be provided in accordance with CDC r recommendations and GHC protocols.

Nothing

Not covered: Physical exams required for obtaining or continuing employment or insurance.

All charges.

Childhood immunizations recommended by the American Academy of Pediatrics

Well-child care charges for routine examinations, immunizations and care (up to age 22)

Examinations, such as:

- Eye exams through age 17 to determine the need for vision correction

- Ear exams through age 17 to determine the need for hearing correction

Examinations done on the day of immunizations (up to age 22)

Physical exams required for travel or for attending school or camp.

NOTE: Travel related immunizations may be provided in accordance with CDC recommendations and GHC protocols.

Nothing to age 18

$10 per office visit age 18 and older

Complete maternity (obstetrical) care, such as:

Prenatal care

Delivery

Postnatal care

Note: Here are some things to keep in mind:

You do not need to precertify your normal delivery; see page 10 for other circumstances, such as extended stays for you or your baby.

You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary.

We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self and Family enrollment.

Circumcision is covered as a surgery benefit, not as a Maternity benefit. See Section 5(b).

We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and Surgery benefits (Section 5b).

$10 for initial maternity office visit

Nothing for all other maternity related office visits

Not covered: Routine sonograms to determine fetal age, size or sex.

All charges.

A range of voluntary family planning services, limited to: Voluntary sterilization (See Surgical procedures Section 5 (b))

Surgically implanted contraceptives

Injectable contraceptive drugs (such as Depo provera)

Intrauterine devices (IUDs)

Diaphragms

Note: We cover oral contraceptives under the prescription drug benefit.

$10 per office visit

Not covered:

Reversal of voluntary surgical sterilization

Genetic counseling.

All charges.

Diagnosis and treatment of infertility such as:

Artificial insemination:

- intracervical insemination (ICI)

Fertility drugs

Note: We cover injectable fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefit.

$10 per office visit

Not covered:

Assisted reproductive technology (ART) procedures, such as:

- in vitro fertilization

- embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)

Services and supplies related to ART procedures

Cost of donor sperm

Cost of donor egg

Injectable and oral fertility drugs, except for Clomiphene citrate.

All charges.

Testing and treatment

Allergy injections

$10 per office visit

Allergy serum

Nothing

Not covered: Provocative food testing and sublingual allergy desensitization

All charges.

Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on page 25.

Respiratory and inhalation therapy

Dialysis – hemodialysis and peritoneal dialysis

Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy

Growth hormone therapy (GHT)

Note: Growth hormone is covered under the prescription drug benefit.

Note: – We only cover GHT when we preauthorize the treatment. Call your primary care provider for preauthorization. If we determine that GHT is not medically necessary, we will not cover the GHT or related services and supplies.

$10 per office visit

Not covered:

All charges.

40 visits for the services of each of the following:

qualified physical therapists and

occupational therapists

Note: We only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or injury.

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction is provided for up to 36 sessions.

One follow-up visit six months after the date of your last physical or occupational therapy treatment.

$10 per initial office visit per condition

Nothing per visit during covered inpatient admission

Not covered:

Long-term rehabilitative therapy

Exercise programs(except in therapy programs listed above)

All charges.

60 consecutive days per condition for the services of qualified speech therapists

$10 per initial office visit per condition

Nothing per visit during covered inpatient admission.

Hearing testing

Nothing to age 18

$10 per office visit age 18 and older

Hearing aid coverage limited to one (1) hearing aid per ear every thirty-six (36) months. GHC pays 50% of $2000 for a maximum payment of $1000 by GHC.

All charges above benefit maximum

Annual vision examinations

Annual eye refractions

One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery (such as for cataracts)

Note: See Preventive care, children for eye exams for children.

Nothing to age 18

$10 per office visit age 18 and older

Not covered:

Eyeglasses or contact lenses and after age 17, examinations for them

Eye exercises and orthoptics

Radial keratotomy and other refractive surgery

All charges.

Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.

Note: See Orthopedic and prosthetic devices for information on podiatric shoe inserts.

$10 per office visit

Not covered:

Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above

Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)

All charges.

Artificial limbs and eyes; stump hose

Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy

Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant following mastectomy. Note: See 5(b) for coverage of the surgery to insert the device.

Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

Braces

Foot Orthotics available to Diabetes and Rheumatoid Arthritis patients with foot complications. Referral required.

Cochlear Implanted Devices

20% coinsurance per item

Not covered:

Orthopedic and corrective shoes

Arch supports

Foot orthotics(except as noted above)

Heel pads and heel cups

Lumbosacral supports

Corsets, trusses, elastic stockings, support hose, and other supportive devices

Prosthetic replacement unless the item is no longer useful and has exceeded its reasonable lifetime under normal use; or the member’s condition has changed so as to make the original equipment inappropriate.

All charges.

Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician, such as oxygen and dialysis equipment. Under this benefit, we also cover:

Hospital beds;

Standard Wheelchairs; Crutches;

Walkers;

Blood glucose monitors; and

Insulin pumps.

Note: Call us at 608/257-5294 as soon as your Plan physician prescribes this equipment. We will arrange with a health care provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

20% coinsurance per item (per purchase or rental period)

Not covered: Motorized wheelchairs.

DME replacement unless the item is no longer useful and has exceeded its reasonable lifetime under normal use or the member’s condition has changed so as to make the original equipment inappropriate.

All charges.

Home health care ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide.

Nothing

Not covered:

Nursing care requested by, or for the convenience of, the patient or the patient’s family;

Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative.

All charges.

Manipulation of the spine and extremities

Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application

$10 per office visit

Not covered:

Chiropractic services for chronic problems or for maintenance

All charges.

Complementary Medicine Services, when provided by a GHC Complementary Medicine practitioner, are limited to 50% of first $500 in eligible charges, with a maximum payment by GHC of $250 per calendar year. Covered services include:

Acupuncture

Manual Therapy

Massage Therapy

Energy Work

Stress Reduction

Mind/Body Medicine

Mindfulness Therapy, including Mindfulness Meditation

Eastern Practices

Yoga

T’ai Chi

Movement Therapy

Wellness Classes

Lifestyle Change Classes

Herbal Medicine

All charges above benefit maximum

Coverage may include:

Smoking

Diabetes self management

Nutrition

Weight Management

Stress Management

Prenatal Education

First Aid

Fitness Program – GHC’s ‘Exercise for Excellence’ offers reimbursements to qualified participants.

Some fees apply.

Contact the GHC Health Promotion Department at 608-257-9705 for program and fee schedules.

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Here are some important things you should keep in mind about these benefits:

Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care.

We have no calendar year deductible.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5(c) for charges associated with the facility (i.e. hospital, surgical center, etc.).

YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.

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A comprehensive range of services, such as:

Operative procedures

Treatment of fractures, including casting

Normal pre- and post-operative care by the surgeon

Correction of amblyopia and strabismus

Endoscopy procedures

Biopsy procedures

Removal of tumors and cysts

Correction of congenital anomalies (see Reconstructive surgery)

Surgical treatment of morbid obesity—a condition in which an individual weights 100 pounds or 100% over his or her normal weight according to current underwriting standards; eligible members must be age 18 or over

Insertion of internal prosthetic devices. See 5 (a) – Orthopedic and Prosthetic devices for device coverage information

Voluntary sterilization (e.g., Tubal ligation, Vasectomy)

Treatment of burns

Note: Generally we pay for internal prosthesis (devices) according to when the procedure is done. For example we pay Hospital benefits for a pacemaker and Surgery benefits for insertion of the pace maker

$10 per office visit

Nothing for in-patient hospital visits

Not covered:

Reversal of voluntary sterilization

Routine treatment of conditions of the foot; see Foot care

All charges.

Surgery to correct a functional defect

Surgery to correct a condition caused by injury or illness if:

- the condition produced a major effect on the member’s appearance and

- the condition can reasonably be expected to be corrected by such surgery

Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; webbed fingers; and webbed toes.

All stages of breast reconstruction surgery following a mastectomy, such as:

- surgery to produce a symmetrical appearance of breasts;

- treatment of any physical complications, such as lymphedemas;

- breast prostheses and surgical bras and replacements (see Prosthetic devices)

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.

$10 per office visit

Nothing for in-patient hospital visits

Not covered:

Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury

Surgeries related to sex transformation

All charges.

Oral surgical procedures, limited to:

Reduction of fractures of the jaws or facial bones;

Surgical correction of cleft lip, cleft palate or severe functional malocclusion;

Removal of stones from salivary ducts;

Excision of leukoplakia or malignancies;

Excision of cysts and incision of abscesses when done as independent procedures; and

Other surgical procedures that do not involve the teeth or their supporting structures.

Surgical removal in fully impacted teeth

Non-dental treatment of temporomandibular joint syndrome including surgical and non-surgical intervention, corrective orthopedic appliances and physical therapy

$10 per office visit

Nothing for in-patient hospital visits

Dental treatment of temporomandibular (TMJ syndrome – limited to a maximum plan payment of $1250 per person per calendar year for non-surgical treatment.

NOTE: a physical therapy evaluation is required before an intraoral splint is considered as a treatment option.

All charges above benefit maximum

Not covered:

Oral implants and transplants

Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)

All charges.

Limited to:

Cornea

Heart

Heart/lung

Kidney

Kidney/Pancreas

Liver

Lung: Single – Double

Pancreas

Allogeneic (donor) bone marrow transplants

Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute lymphocytic or non-lymphocytic leukemia; advanced Hodgkin’s lymphoma; advanced non-Hodgkin’s lymphoma; advanced neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal, retroperitoneal and ovarian germ cell tumors

Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver, stomach, and pancreas

National Transplant Program (NTP) – UW Hospital and Clinics

Limited Benefits – Treatment for breast cancer, multiple myeloma, and epithelial ovarian cancer may be provided in a National Cancer Institute – or National Institutes of Health-approved clinical trial at a Plan-designated center of excellence and if approved by the Plan’s medical director in accordance with the Plan’s protocols.

Note: We cover related medical and hospital expenses of the donor when we cover the recipient.

$10 per office visit for evaluation

Nothing in hospital

Not covered:

Donor screening tests and donor search expenses, except those performed for the actual donor

Implants of artificial organs

Transplants not listed as covered

All charges.

Professional services provided in –

Hospital (inpatient)

Nothing

Professional services provided in –

Hospital outpatient department

Skilled nursing facility

Ambulatory surgical center

Office

$10 per office visit

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Here are some important things you should keep in mind about these benefits:

Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.

We have no calendar year deductible.

Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge (i.e., physicians, etc.) are in Sections 5(a) or (b).

YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to Section 3 to be sure which services require precertification.

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Room and board, such as

Ward, semiprivate, or intensive care accommodations;

General nursing care; and

Meals and special diets.

Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

Other hospital services and supplies, such as:

Operating, recovery, maternity, and other treatment rooms

Prescribed drugs and medicines

Diagnostic laboratory tests and X-rays

Administration of blood and blood products and biologicals

Blood or blood plasma, if not donated or replaced

Dressings, splints, casts, and sterile tray services

Medical supplies and equipment, including oxygen

Anesthetics, including nurse anesthetist services

Take-home items

Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

Nothing

Not covered:

Custodial care

Non-covered facilities, such as nursing homes, schools

Personal comfort items, such as telephone, television, barber services, guest meals and beds

Private nursing care

All charges.

Operating, recovery, and other treatment rooms

Prescribed drugs and medicines

Diagnostic laboratory tests, X-rays, and pathology services

Administration of blood, blood plasma, and other biologicals

Blood and blood plasma, if not donated or replaced

Pre-surgical testing

Dressings, casts, and sterile tray services

Medical supplies, including oxygen

Anesthetics and anesthesia service

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures.

Nothing

Not covered: Blood and blood derivatives not replaced by the member

All charges.

Extended care benefit: We provide a comprehensive range of benefits for up to 100 days per calendar year when full-time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor and approved by the Plan.

Nothing

Not covered: Custodial care

All charges.

Supportive and palliative care for a terminally ill member is covered if care is provided in the home. Covered in-home services include: nursing services; medical social services; dietary, bereavement and spiritual counseling services; rehabilitative services; and home health aides.

Nothing for in-home services

Coverage for other hospice options, including but not limited to inpatient and residential care, will be at the same cost level as for in-home care with the Member responsible for any difference in cost.

Hospice services are provided under the direction of a Plan physician and the GHC Medical Director who certify that the Member is in the terminal stage of an illness, with a life expectancy of six (6) months or less.

You pay the difference in cost between GHC’s in-home care allowance and actual costs as billed by the hospice organization

Not covered: Independent nursing, homemaker services

All charges.

Professional ambulance service when medically appropriate.

Note: See 5(c) for non-emergency service.

Nothing

Not covered: Ambulance services to home following an inpatient stay.

All charges.

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Here are some important things to keep in mind about these benefits:

Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

We have no calendar year deductible.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

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What is a medical emergency?

A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies – what they all have in common is the need for quick action.

What to do in case of emergency:

Emergencies within our service area:

If you are in an emergency situation, please call your primary care provider. In extreme emergencies, if you are unable to contact your provider, contact the nearest emergency system (e.g., the 911 telephone system) or go to the nearest hospital emergency room. Be sure to tell emergency room personnel that you are a GHC plan member so that they can notify us. You or a family member must also notify us within 48 hours. It is your responsibility to make certain that the Plan has been notified.

If you need to be hospitalized in a non-Plan facility, you or a family member must notify the Plan within 48 hours or on the first working day following your admission, unless it is not reasonably possible to do so. If a GHC plan doctor believes you will receive better care in a plan hospital, we will transfer you when it is medically feasible and we will pay all ambulance charges for the transfer.

Benefits are available for care by non-Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death, disability or significant jeopardy to your condition.

Any follow-up care recommended by non-Plan providers in such a medical emergency must be approved by GHC or provided by GHC plan providers.

Emergencies outside our service area:

Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness.

If you need to be hospitalized, you or a family member must notify the Plan within 48 hours or on the first working day following your admission, unless it is not reasonably possible to do so. If a GHC plan provider believes you will receive better care in a Plan hospital, we will transfer you when it is medically feasible and we will pay all ambulance charges for the transfer.

Any follow up care recommended by non-Plan providers in such a medical emergency must be approved by GHC or provided by GHC plan providers.

Emergency care at a doctor’s office

Emergency care at an urgent care center

$10 per visit

Emergency care as an outpatient a hospital, including doctors’ services

$50 per visit, waived if admitted as an inpatient

Not covered: Elective care or non-emergency care

All charges.

Emergency care at a doctor’s office

Emergency care at an urgent care center

$10 per visit

Emergency care as an outpatient at a hospital, including doctors’ services

$50 per visit, waived if admitted as an inpatient

Professional ambulance service when medically appropriate.

Note: See 5(c) for non-emergency service.

Nothing

Not covered: Ambulance services to home following an inpatient stay.

All charges.

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When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations for Plan mental health and substance abuse benefits will be no greater than for similar benefits for other illnesses and conditions.

Here are some important things to keep in mind about these benefits:

Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

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All diagnostic and treatment services recommended by a Plan provider and contained in a treatment plan that we approve. The treatment plan may include services, drugs, and supplies described elsewhere in this brochure.

Note: Plan benefits are payable only when we determine the care is clinically appropriate to treat your condition and only when you receive the care as part of a treatment plan that we approve.

Your cost sharing responsibilities are no greater than for other illnesses or conditions.

Professional services, including individual or group therapy by providers such as psychiatrists, psychologists, or clinical social workers

Medication management

$10 per visit

Diagnostic tests

Nothing

Services provided by a hospital or other facility

Services in approved alternative care settings such as partial hospitalization, half-way house, residential treatment, full-day hospitalization, facility based intensive outpatient treatment

Nothing

Not covered: Services we have not approved.

Note: OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness. OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another.

All charges.

Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following network authorization processes:

GHC Plan patient may make their own appointments without a referral for Mental Health and/or Substance Abuse services as follows:

Mental Health: contact GHC Mental Health Department at 608-441-3290 (after hours 608-257-9700; out of area 1-800-605-4327);

Substance Abuse: contact Gateway Recovery Services, Inc. 608-278-8200.

Limitation We may limit your benefits if you do not obtain a treatment plan.

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Here are some important things to keep in mind about these benefits:

We cover prescribed drugs and medications, as described in the chart beginning on the next page.

All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

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There are important features you should be aware of. These include:

Who can write your prescription. A plan physician, a referral physician or a licensed dentist must write the prescription.

Where you can obtain them. You must fill the prescription at a Plan pharmacy

We use a formulary. A drug formulary is a list of prescription medications, representing the current judgment of medical practitioners, for the treatment of disease.Not all medications will be listed in the formulary, particularly when there are several similar medications available. The formulary will include the drugs covered by the plan’s benefit. Your physician/practitioner may request coverage for non-formulary drugs when clinically necessary.

These are the dispensing limitations. We cover the amount prescribed, up to a 30-day supply maximum, or One (1) commercially prepared unit (such as one vial ophthalmic drops, one inhaler, one tube of ointment), per co-payment. If coverage has been approved for a non-formulary drug, you pay the applicable generic or brand name copayment. For non-formulary drugs when coverage has not been approved, the copayment is equal to the plan calculated total prescription cost, which is generally lower than the retail price

A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand. If you receive a name brand drug when a Federally-approved generic drug is available, and your physician has not specified Dispense as Written for the name brand drug, you have to pay the name brand copay plus difference in cost between the name brand drug and the generic.

If you are a military reservist called to active duty or are a member requiring a supply of medication during a national emergency, call us at 608-828-4853 for assistance with obtaining your medication.

Why use generic drugs? Generic drugs offer a safe and economic way to meet your prescription drug needs. The generic name of a drug is its chemical name; the brand name is the name under which the manufacturer advertises and sells a drug. Under federal law, generic and name brand drugs must meet the same standards for quality. A generic prescription costs you less and helps moderate the costs of providing healthcare

When you do have to file a claim. Generally you will not need to file a claim. An exception would be a drug prescribed in an emergency or urgent situation when you are out of the area. Forward such claims to the GHC Claims Department, PO Box 44971, Madison WI 53744-4971. Be sure to include your member number and an explanation of why you are submitting the claim.

We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy:

Drugs and medicines that by Federal law of the United States require a physician’s prescription for their purchase, except those listed as Not covered.

Insulin

Diabetic supplies, including insulin syringes, needles, injection pens, glucose test tablets and test tape, Benedict’s solution or equivalent and acetone test tablets

Disposable needles and syringes for the administration of covered medications

Contraceptive drugs and devices

Smoking cessation drugs when participating in the Plan’s behavior modification program

Pre-natal vitamins during pregnancy

Oral fertility drugs, Clomiphene citrate, limited to a lifetime maximum of one year

$5 copay for generic drugs

$20 copay for name brand drugs

Note: If there is no generic equivalent available, you will still have to pay the name brand copay.

Note: Patients wishing to use a formulary name brand medication instead of a covered generic equivalent may choose to do so but will pay the cost difference between the formulary brand and the formulary generic in addition to the brand copay.

Drugs for sexual dysfunction are subject to dosage limits. Contact the Plan for details.

50% copayment

Not covered:

Drugs and supplies for cosmetic purposes

Drugs to enhance athletic performance

Fertility drugs except Clomiphene citrate

Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies

Vitamins, nutrients and food supplements even if a physician prescribes or administers them

Nonprescription medicines

All charges.

Services for deaf and hearing impaired

Hearing impaired interpreter for non-emergency services can be reached at this TDD line: 608/257-7391.

Centers of excellence

Our local Center of Excellence is associated with the University of Wisconsin Hospital and Clinics in Madison WI.

Travel benefit

Travel related immunizations may be provided in accordance with CDC recommendations and GHC protocols.

We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must result from an accidental injury.

You must be seen an evaluated within 48 hours of the accident; however, the start of treatment may be delayed no longer than 90 days following the accidentally injury.

NOTE: Damage to teeth caused by chewing or biting does not constitute an accidental injury.

Nothing up to $1500